Clinical Issues With Transgender Individuals

Transgender is an umbrella term that encompasses a variety of people including transsexuals, cross dressers, and drag kings and queens, as well as bigender andandrogynous individuals Tewksbury & Gagne, 1996). Transgender, as a term, came into common usage during the 1980s. Previously, people with mixed gender and sexual characteristics were described as transsexuals and transvestites, terms that come from the psychiatric vocabulary. Transgender comes from the transgender community itself and is, therefore, the preferred term in working with transgender individuals.

The psychiatric model views both transsexuality and transvestitism as psychopathological in nature. Transsexuality is viewed by this model as an insufficient identification with the same-sex parent or overidentification with the opposite-sex parent in infancy or early childhood. Transvestitism, understood as an abnormal dependence on wearing female attire for sexual arousal, was also traced to early childhood experiences (Warren, 1997; Docter, 1990; Denny, 1994).

In addition, medical models of transsexuality currently are being explored. These models focus on physiological etiology and range from prenatal hormonal effects on the fetus to differencesin brain structure. However, neither the psychiatric nor medical models for defining transgender individuals have been accepted by the transgender community.

Research on the various theories of the medical model of transgender experience has led the transgender community to question the role the psychiatric and medical fields play in providing services. In order to avoid malpractice issues, medical doctors currently require two letters from psychotherapists supporting sex reassignment before they will approve a transsexual for sex reassignment surgery. The transgender community strongly advocates that the current psychiatric classification for gender identity disorder (GID), 302.85, should be eliminated from the Diagnostic and Statistical Manual of Mental Health (Fourth Edition) (DSM–IV). These concerns have caused a vigorous and ongoing discussion about how well the medical and psychiatric fields serve the needs of the transgender community.

In a society and culture that perceives them as “sick,” “abnormal,” and having a disorder, it is no surprise that transgender individuals sometimes seek escape from hatred, violence, discrimination, and misunderstanding through the use of alcohol and drugs. Transphobia (the irrational fear and dislike of transgender individuals) is a part of our culture. Because they live in a society that discriminates against them, condones violence against them, and denies them basic civil rights, many transgender individuals have internalized the prejudices of their culture and ended up hating themselves. Substance abuse treatment providers may be some of the few people to whom transgender individuals will talk about their feelings and pain. The substance abuse counselor has an opportunity while helping transgender individuals with their substance abuse issues to refer them to resources to help them cope with their transgender issues.